Diabetes Mellitus and Hypoglycaemia

Question 1

What is the main aim of the treatment of diabetes?

Answer 1

To alleviate symptoms and minimise the risk of long-term complications.

Question 2

How can the increased risk of CVD associated with diabetes be reduced?

Answer 2

By use of an ACEi and lipid-regulating drugs.

Question 3

What does glycosylated haemoglobin (HbA1c) provide a good indication of? How frequently should it be measured?

Answer 3

Glycaemic control over the past 2-3 months, it should be measured every 3-6 months.

Question 4

What is the ideal HbA1c concentration to aim for in patients with diabetes? (This is different to the reference range).

Answer 4

59 mmol/L or less.

Question 5

What is the reference range for HbA1c in a healthy patient?

Answer 5

20-42 mmol/L.

Question 6

Why is the target HbA1c different in a patient with diabetes compared to the reference range of a healthy patient?

Answer 6

Because it is not always achievable and can lead to an increased risk of severe hypoglycaemic episodes.

Question 7

How would one test for diabetic nephropathy?

Answer 7

Via urinary microalbuminuria, annual test for urinary proteins, and serum creatinine.

Question 8

Presence of diabetic nephropathy increases one’s risk of developing which electrolyte abnormality?

Answer 8

Hyperkalaemia.

Question 9

How should all diabetic patients with diabetic nephropathy be treated?

Answer 9

With ane ACEi or ARB, regardless of blood pressure. Blood pressure should also be carefully monitored to minimise renal deterioration.

Question 10

What characteristic of ACEi should be taken into account when they are used in patients with diabetes?

Answer 10

They can potentiate the hypoglycaemic effect of anti-diabetic drugs and insulin, especially during initial treatment and in renal failure. Increased risk of hypoglycaemia.

Question 11

How should mild to moderate pain in diabetic neuropathy be treated?

Answer 11

With paracetamol or ibuprofen.

Question 12

How should painful diabetic neuropathy be treated?

Answer 12

With duloxetine.

Question 13

Which drugs can be used if duloxetine is ineffective in treating pain in diabetic neuropathy?

Answer 13

Nortriptyline or amitriptyline (unlicensed).

Question 14

If duloxetine, amitriptyline, and nortriptyline are all ineffective in treating pain in diabetic neuropathy, which drug can be tried?

Answer 14

Gabapentin.

Question 15

In severe pain in diabetic neuropathy, there is evidence to suggest which drugs may be effective?

Answer 15

Tramadol. Additionally, morphine and oxycodone may be used under specialist supervision.

Question 16

What blood sugar level defines hypoglycaemia?

Answer 16

A blood sugar of less than 3.5 mmol/L.

Question 17

What are the symptoms of hypoglycaemia?

Answer 17

Pale skin, feeling sweaty, tremor, rapid heart rate, confusion, aggression, fits, impaired consciousness.

Question 18

What is the main aim of treating hypoglycaemia?

Answer 18

Immediate restoration of blood glucose levels.

Question 19

How is hypoglycaemia treated in a cooperative and conscious patient?

Answer 19

By administration of oral glucose.

Question 20

How is hypoglycaemia treated in an unconscious patient?

Answer 20

By administration of IV dextrose.

Question 21

How is hypoglycaemia treated in an unconscious patient with no IV access?

Answer 21

By administration of an IM glucagon injection.

Question 22

What are the symptoms of diabetic ketoacidosis/hyperosmolar non-ketosis?

Answer 22

Dehydration, acute hunger, thirst, abdominal pain, fruity smelling breath and urine (if ketotic), rapid breathing, confusion, decreased consciousness, and arrhythmias (due to hyper/hypokalaemia).

Question 23

In which type of diabetes is diabetic ketoacidosis more common?

Answer 23

Type 1.

Question 24

Which has a higher rate of mortality DKA or HONK?

Answer 24

HONK.

Question 25

How is DKA defined?

Answer 25

Hyperglycaemia > 20mM with the presence of ketones.

Question 26

DKA may be exacerbated by the vomiting present in the condition, increasing dehydration and potassium loss. What causes this vomiting?

Answer 26

The presence of ketones irritating the vomiting centre.

Question 27

In which group of diabetic patients is HONK often seen?

Answer 27

Undiagnosed patients.

Question 28

Define HONK.

Answer 28

Hyperosmolar non-ketosis. Severe dehydration due to hyperglycaemia > 50mM. Some insulin is present so minimal ketones are seen.

Question 29

How are DKA and HONK managed?

Answer 29

Use of NG tube to remove stomach contents and prevent aspiration. IV insulin and fluids. Use of LMWH to prevent clotting. Use of a urinary catheter to monitor fluids and assist immobile patients. Use of a sliding scale of insulin to tightly control glucose levels. Fluid, potassium, and phosphate replacement. Consider Abx if caused by infection.

Question 30

What is the NICE guidance for the treatment for T2DM?

Answer 30

Metformin monotherapy. If contraindicated, consider a gliptin, pioglitazone, or sulfonylurea. Then metformin dual therapy with a gliptin, pioglitazone, or a sulfonylurea. If metformin contraindicated gliptin + pioglitazone, gliptin + sulfonylurea, pioglitazone + sulfonyurea.